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Why Ebola is Hard to Contain

(I am no epidemiologist, so don’t take information here as actual medical advice. I’m an educator, and that’s what this post is supposed to be about.)

As you all are well aware, the outbreak of Ebola in West Africa is a serious problem right now.

Ebola is a dangerous and scary disease. It’s “highly infectious” and has a 50%-90% death rate (this epidemic is currently 55%-60%). There is no vaccine or treatment for the disease.

These facts, along with sensationalist news coverage and public fears make Ebola sound like it’s an unstoppable super disease that will defy all modern science and efforts to contain it.

But that’s simply not true. Ebola is actually very simple to avoid and contain. You only need to do two things: 1) Do not come into contact with the body fluids of a person who is gravely ill (or dead), and 2) Do not eat / handle bush meat (especially bats and primates who are known reservoirs for the virus).

That’s it. It’s that simple. Here’s a poster from the CDC you can put on your wall.

Let me put it another way: If someone isn’t exhibiting the severe symptoms of the illness, you can’t catch it from them. That is, unless they wipe someone else’s infected body fluids on you. Or give you some infected bushmeat to eat.

As David Heymann, professor of infectious disease epidemiology at the London School of Hygiene and Tropical Medicine (LSHTM) says: “It’s not rocket science”

Sure, we don’t have a vaccine or available treatment. Sure, it’s deadly. But this should not be hard to contain, right? I mean, it’s not like the virus is airborne, like in the movie Contagion… Just quarantine current cases and get people to stop eating bush meat. Follow proper procedures to clean contaminated areas. That’s all there is to it.

So if this problem has such a clear and well-defined scientific/medical solution, how did this epidemic get “totally out of control”? Why wasn’t this properly contained when it first broke out? Why is this so hard to stop?

Well, one obvious reason is that there hasn’t been the medical and organizational capacity on the ground to implement the measures needed to contain this thing. The VP of Samaritan’s purse told congress in a recent presentation that the international community was slow to respond, and “that the world would allow two relief agencies to shoulder this burden along with the overwhelmed ministries of Health in these countries testifies to lack of serious attention this epidemic was given”.

But there have been other challenges too: People try to “rescue” their dying relatives, forcibly removing them from the hospital and carrying them home where they infect their whole families. Communities have stoned health care workers because they think the doctors are spreading the disease. People are continuing traditional burial practices that spread the disease and refusing to modify them. People with symptoms are refusing to go to the hospital and be quarantined. What is going on here??

Well, to put it in Liberian English: “Ebola not scientific/medical problem; that human being problem”.

Even if you assume a perfectly organized and well-funded response from the Liberian government and the international community, there’s a “perfect storm” of cultural, educational, and social factors that are making all efforts to contain this disease a nightmare.

While I’m speaking from my observations in Liberia, keep in mind that most of the challenges I describe here are common to (West) Africa as a whole. It’s also important to note that even though I make some pretty wide-sweeping assertions, I recognize there’s always exceptions to generalizations. But generalizations are still useful to create a “big picture” understanding of a complex interaction of variables.

Here we go…

Liberian Culture Does Not Quarantine

Liberians, as a rule, never spend time alone. Everybody does everything together, and people are never excluded from the group. In western culture, we often balance our time spent in groups with time with time spent alone, but Liberians do not do this — they are always with someone.

If you come along and suggest to a Liberian that because they’re sick they need to be put away in an isolated room, they’ll look at you like you’re crazy. To them, when you’re sick, you need the support and presence of your friends and family the most!

With that in mind, it’s easy to understand why infected people are escaping their quarantines and running home to be with their families. It’s also why people aren’t going to the hospital in the first place. A quarantine seems so cruel and unusual, it’s hard for people to see how necessary it is.

Instead, they’ll wait until the last minute because they are optimistic: “surely there’s another way…”, they think, “we’ll figure something out… God will save me… I won’t make my family sick… I probably don’t have Ebola… the doctors are wrong, and just trying to scare me…”

…which brings me to the next item on my list.

Liberians Are Perpetually Optimistic, Empathetic, and Flexible

Have you seen a Liberian pack a taxi? It’s nuts. To a westerner, the average car will hold five people (including the driver) along with some assorted luggage. To the Liberian, that same taxi will hold ten people, all their luggage, market goods, a couple animals, a king sized bed (strapped on the roof), the kitchen sink and a couple more bags of coal for good measure.

You tell them, “there’s no way we’ll fit all these people and things into this taxi”, and they’ll say, “Don’t worry! It will make it!”. And many times, they DO make it, even if they end up having to drive at 10mph because their wheels are scraping the top of their wheel wells.

Here, boundaries and limits are not seen as absolute. Everything is negotiable, everything can be stretched, and anything is possible. You never assume or prepare for the worst even when things look really bad because you never know what might be just around the corner.

You would think this attitude results in people getting themselves into awful pickles, and it does. But since another big part of the culture here is helping those in need, it all sort of works out in the end. Maybe you’ve created an unnecessary crisis for yourself by biting off more than you can chew, but you’ll always find someone to help you out of it.

As a consequence, if you try to enforce hard limits that are not related to a physical impossibility, you are seen as cruel and heartless. No taxi driver will turn away that one last person that needs the ride (“we will manage it!”), no mother turns away a hungry mouth if there’s still food in the pot, no self-respecting friend will refuse to help his brother in need… so why are you not letting them visit their relative in quarantine?? I can see the door to his room from here, and you’re telling me I can’t go there?? He’s sick and needs me for heaven sakes!!! Why aren’t you letting me take the poor man home?!? Why won’t you help me just this once?? I beg you!

In order for a quarantine to work, you need to be inflexible about your boundaries and procedures. No exceptions. No matter how emotionally desperate someone is, you have to say “no”. To a Liberian however, this does not compute. There’s no visible physical boundary you can point to that will make them understand. In their minds, rules without physical limits always have exceptions. There’s always flex in boundaries. If you aren’t flexing, it must be because you are a cruel and unusual person. (And health workers being seen as cruel and unusual doesn’t help the “trust issues” that I’ll be discussing in a moment…)

In order to run an effective quarantine, you need people at all levels of society cooperating by following proper procedure and respecting the established boundaries. That means guards must be inflexible about letting people in and out. That means medical personnel must be inflexible about their hygiene procedures. That means the public needs to be inflexible about reporting suspected cases. From top to bottom, the entire society needs to work together to make the quarantine work.

So how do we get people to start making decisions based on the rational need of a quarantine instead of emotional reaction to specific cases? Well, the ability to make and value rational actions over emotional ones comes with education.

…which brings me to the next item on my list.

Education Challenges

Liberia’s education system is still struggling to be rebuilt after being disrupted by years civil war and conflict. My job as a Peace Corps Volunteer is to aid in this reconstruction process.

I’ve always seen education as the driving force behind a nation’s health and prosperity. Education allows us to critically examine information; to discern the difference between a fact and an intuition. It can be the difference between a population organizing itself to solve a problem and panicking over a rumor.

Not to toot my own horn here, but math / science education is especially important. You develop attention to detail, the ability to follow procedures, and a respect for laws that are either invisible or not immediately obvious. You develop an intuition for relative magnitudes — which is essential for managing risk. Think about how all these skills are used in making the following judgements:

Should I be more worried about shaking a random person’s hand, or cleaning my brother’s sheets, who just died from Ebola?

Should I give this Ebola victim a traditional washing and burial, or consider making some compromises and adjustments to the process to protect myself and my family?

When my father starts exhibiting Ebola symptoms, should I call the Ebola hotline and report the case, or give him some random pills and pray for it to stop?

etc.

A good math / science education prepares you to deal with reality and be critical of your personal biases. When you see how you can use known physical laws to predict outcomes, you begin to realize that there is an order to the universe that can be trusted. The laws of gravity are always obeyed. This doesn’t make gravity cruel and unusual… in fact, it makes gravity something we can trust and count on.

…and knowing who/what we can trust and count on brings me to the final and most important item on my list.

Trust Issues

When the first few cases of Ebola were being reported, a significant portion of the Liberian public was skeptical. They dismissed the reports as rumors, or false reports made by the Liberian government in order to attract more aid money.

Then people became worried that the doctors were the ones spreading the disease, or capitalizing on it to harvest organs and do medical experiments.

People still think that if they go to a clinic right now (for any medical problem) a doctor will lock them in a room and let them starve until they die, and then pronounce the cause of death as “Ebola”.

When it comes down to it, Liberians don’t trust their leaders or the international community to have their best interests in mind… let alone to have the capacity to coordinate an organized and comprehensive effort to save them. So they figure their safest option is to just stay home when they get sick. The problem with this line of thought, as I talked about at the beginning of this post, is that as long as people stay home instead of report to a quarantine facility, the outbreak will continue to spread.

From a western perspective, all these fears of incompetence and people’s suffering being used as gain almost sound too horrible to even be possible. But the sad fact is, if you look at the region’s unstable and brutal history and then put yourself into their shoes, I think their fears start making a lot of sense.

I mean, people are already finding ways to benefit on this current crisis. Before I left the country I heard one report of people selling injections of an “Ebola vaccine”. As you know, there is no such thing. It was a group of criminals just trying to make some extra money. And who knows what they were injecting people with.

My point is, in the western world we have organizations that have built a certain level of trust with the general population. We tend to trust reputable scientists, doctors, and government officials and follow their instructions, especially in crisis situations. It’s easy to weed out fringe voices. But when you consider that sometimes even we have problems trusting our officials on simple matters, can you imagine how hard it is for someone in Liberia with their history?

I think that it should be clear that any effort to contain this outbreak should come in two parts: first, medical capacity including trained personnel and equipment, and second, massive public education and trust building. You need both parts to beat this thing… any failure on one front will sink the other.

And finally, what really makes this hard is that you need 100% compliance. If there’s 100 Ebola cases and you only get 99 in your quarantine, the disease can still spread. With the virus in such populated areas, how do we get 100% compliance? How do we mobilize the resources needed to handle all the possible cases? The depth of this problem is huge. Even though Peace Corps keeps assuring me that this crisis will be under control in the next couple months, I’m not so certain. I think things are going to get much worse before they start getting better.

So right now I’m working on ways I can help on the Ebola education and community outreach front, even while I’m still in America. Right now I’m just trying to develop as many contacts as possible. If you know anybody with any kind of connection to Liberia, (individuals, churches, companies, etc.) please connect me with them!

By Kyle Husmann. Kyle is an MTI partner who was teaching mathematics in Liberia for the Peace Corps.